Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Friday, April 10, 2009

Calling all ER docs, nurses, techs, and my paramedic friends! I don't know if this has been done elsewhere but if it hasn't I don't know why. I am calling on all of you to submit, in the comment thread, your worst example of ER or EMS abuse that you have personally witnessed.

Please, no second hand stories, and please do not embellish... I think the stories by themselves will be amazing enough. Let's have it ladies and gentlemen, and as a prod I will start with the patient that inspired this post... a young man came to see me tonight because his chest hurt and he felt like there were bugs under his skin. He refused to believe me when I told him it was a direct cause of the crystal meth he was smoking every few hours, and I was forced to do a complete cardiac workup on him paid for by you, of course. He also had the temerity to ask for a work note. Hardly an award winner... I know there are lots better stories out there.

The best comments will be added to the body of this post and hopefully we can make it impressive enough to get noticed by folks who don't know what a taxpayer money sponge the ER (and EMS) has become under EMTALA.

Fire away!

I know the comment section will continue to grow and all are worthy of posting here but if I posted them here this post would be a monster. I must point you towards a great piece from our friend "White Coat" who now blogs for money, damn his eyes, at one of our montlhly journals, please check this out and keep the stories coming.

57 comments:

EMS reported it was closer to 300 illegals found in the desert with close to 100 transported to hospitals in Phoenix. The entire west side of Phoenix was overwhelmed with mild to moderately dehydrated patients, in addition to the standard ER chaos. Most Emergency Departments in Phoenix went to internal disaster status to divert ambulances. This also froze EMTALA higher level of care transfers, and the affected hospitals were scrambling to find open ER's that could take surgery, cardiology, ICU, etc patients. Transfers of patients from rural Arizona to Phoenix were similarly frozen. In effect, sick US citizens were relegated to "second class status" by EMTALA in favor of mild to moderately ill non citizens. (and the ER Docs assumed more liability as they were unable to move sick patients). Most of the 100 dehydrated patients were released to the community, as the Feds and the local police/sheriff were overwhelmed.

Not to worry, no hospitals or physicians were reimbursed in the making of this epic (estimated to be in the millions of dollars).

Oh man. I work in Detroit and the classic patient comes in with a minor complaint by EMS because they don't have a car and then expects the hospital to pay for their cab ride home "because I don't have any money." These patients generally smoke cigarettes and always have cell phones. Worst of all, Detroit doesn't triage their EMS calls, so every now and then I get a really sick person (heart attack, exsanguinating from massive nosebleed with 4 gram Hgb drop, etc.) who waited 1-2 hours for an ambulance. Some specific examples:

1) Woman comes in by EMS complaining of "abdominal pain" and give a very vague history until she finally says, "I just want a pregnancy test." Her last period was two and half months ago, she's usually regular, and she had a positive pregnancy test at home. I ask why she came in, and she says, "I didn't trust the home pregnancy test, and I know that yours are better."

2) A(n uninsured) man comes in by private vehicle with chief complaint of "Need MRI." I went to see him and he explained that he wanted to get on disability and was working on a worker's comp case for his neck pain ever since he slipped and fell at work. His lawyer told him that he needed an MRI to file suit, so he came to the ER to get one.

3) A mother with two children under five came in by EMS at 10 pm with cold complaints for everyone. The children were completely normal appearing and didn't even have runny noses. I asked if there was anything else she was here for, and she said that she wanted a pregnancy test. Her last period was four weeks ago but she felt like she should have had it by now. She had not bothered with a home pregnancy test. When she was discharged she did the classic, "I'm going to need a cab ride to get home." I don't think she was worried at all about the children being sick, she just said they were so they could come in the ambulance with her.

4) A woman comes in (by EMS) complaining of some respiratory symptoms although she looks completely normal. Then she says that her landlord was sealing some pipes in the basement and there was a funny odor and she thought she was having trouble breathing. She came in because she wanted to sue him and she knew she would need paperwork from a doctor. She had no medical issues relating to this that I could ascertain. When I discharged her without a diagnosis of inhalational injury or Toxic Death Gas Exposure, she got impressively angry and argued that we didn't even help her with what she came in for.

Pt. decided to leave hospital AMA. Actually left, somehow, with his foley still in. Came back to ER to have it removed. ER wouldn't remove it, for some reason. He got admitted back to floor.

Patient had kidney transplant. Decided not to take his tacrolimus, despite it being free on medicare. Came in with possible kidney rejection. Had kidney biopsy. It was discovered he had a gangrenous foot while there, probably related to his uncontrolled diabetes. Was admitted for IV abx. Vehemently denied having diabetes, despite an a1c of 13%. Ended up getting listed for a pancreas transplant, again, paid for by medicare.

Hi all. I'm a tech and I've seen several abuses of EMS, but there are two in particularthat stick out in my mind. Bear in mind that these people CAME IN BY AMBULANCE.

The first is a young man who came in by ambulance for a 1 cm lack on his palm that was basically a papercut. The treatment was cleaning it with some water and putting ointment and a bandaid on it.

The second was a guy who, I'm not making this up, ate a whole jar of hot sauce which "burned his throat". One of our frequent fliers actually. Treatment if I recall correctly consisted pretty much of telling him not to eat a whole jar of hot sauce again.

I get a really pathetic looking, tired kid, probably about 6 years old, being dragged in by his morbidly obese mother (in a daishiki or a mumu, one of the two), his half asleep sister, and another random family member at 3 am.

So, I pick up the chart and the cheif complaint is as follows:

"Patient's mom states he has had wet farts for the past 6 hours"

Scratching my head, I go in the room, and question mom. "What brings you in at 3 am, ma'am?"

She replies "My kid's been having wet farts for the past 6 hours"

I ask "What do you mean by wet farts?"

She says "Well, you know....every time he farts, a little squirts out...what did you think I meant?"

I reply "Did he wake up complaining? How did you find out?"

She says "No, he's been sleeping. I just want to know why he's got wet farts."

I ask "Did you call your doctor for an appointment? Why did you come in at 3 am for this?"

She said "Because I didn't want to wait till the morning."

So, I look at the kid, he's holding his blanket, half asleep on the bed. I sorta wake him up, and ask him if anything hurts...he said no. I palpate his abdomen, and it's soft, but you can feel the massive amount of shit in his colon.

A KUB and a discharge for constipation with a fleets enema for home use later, I still am left scratching my head.

Why people drag a sleeping kid in for those kind of complaints is beyond me.

Here's a double whammy...my co worker took the ambulance to the er for the stomach flu...guess she didn't want to roll down the window and puke and like the common folk do.A nurse using the ambulance for a taxi...that's really sad.

got a 911 for ill female...frequent flyer, always calls at least 2 times a week, and of course on medicade.....pick her up, she says she has a sore leg....she lives 15 miles outside of city limits...transport her to city E.D., where right after we arrive, signs out AMA, sayin she just needed a ride to town to visit her friend who lives a block away from hospital.

Most recent one: Pregnant woman with no obstetrical complications brought in by EMS for nausea. Within ten minutes, numerous concerned family members arrive--in cars--but patient says she had to take the ambulance because "she didn't have a ride."

One of our frequent fliers called us because her urine was yellow. Other common complaints of hers include: my back is scratchy, I'm having vag bleeding, I'm having chest pain with a cough, and my feet hurt.

Girl came in by EMS because she felt "a bump" while she was masturbating. I had to deal with her mom who was convinced that her daughter was dying of cancer AT THAT VERY MOMENT.

The bump ended up being her cervix. Still not sure how they explained that one to the mom. (And, yes, the patient had private insurance.)

Another one came in via EMS because she was about to give birth. Except that she had been faking the pregnancy all along so that her baby daddy wouldn't dump her. I had to deal with her increasing upset mother -- why can't we see her, has she given birth yet, why isn't she upstairs. The patient was telling the nurses not to send her mom back while simultaneously calling her mom & saying that she was being mistreated, we had caused the baby to die, etc. omg, that was a clusterfuck.

1. my record for most family members seen in the ed at once for the sniffles is 6. mom and 5 kids."medicaid"

2. bibems because "i'm about to run out of dilantin and i want a refill""self pay"

3. bibems for chest pain. on arrival to ed tries to walk out. i stop him to ask about his chest pain- "i didn't have no chest pain. my buddy lives around the corner from this hospital and i wanted a ride.""self-pay"

One of my absolute favorites...DHS brings in a family plan of 5 kids, ages 2-12....Mother had been making Meth in the house...DHS needed urine drug screens on all the kids. We decided it would be much better if the kids just went to the lab to have the urine tests and the ER doc would just send them with orders for the urine instead of triaging them into the ER...when they got over to the lab, the hospital lab would not do the tests because the patients had state medicaid and out lab would not accept it because it does not pay...OMG, but you'll take all five of them into the ER, charge them ER bills plus the price of the labs and the doctor visit...911 you should remember this, you were the MD that day...amazing...

The other day a guy came in via EMS because he needed to get his prescriptions filled. He was discharged earlier that day after getting treated for his broken foot, but couldn't get a ride to a pharmacy. Guess who had to wheel him down to the pharmacy? (I'm a patient transporter) I'm sure he got a cab voucher for his ride home.

Where I live, the county is actually paying one individual a monthly stipend so that she wont call EMS every single day. I think she owes something like 1 million dollars for ambulance rides alone. I always wonder why we don't jail these people, it would be a lot cheaper. Same for those drunks that are "found down" at the bus stop and get a head ct at least once a week (which is invariably negative). It would be cheaper to lock them up in some rehab facility.

1. Toothaches, more times than I care to remember. And we can't really count that one because one of those toothaches was atypical chest pain from an inferior wall MI.

2. A guy requesting that one of us milk his prostate gland, or if we were unwilling, to take him to the ER so the doctor could. We took him to the ER.

3. A paper cut. Literally, a nursing home patient sent to the ER for "uncontrollable bleeding" from a paper cut. The entire blood loss was a dime-sized spot on a 2x2 gauze pad. When questioned as to how she considered this "uncontrollable bleeding," the nurse gave me a blank stare and said, "He's on Coumadin."

4. And the single call that hit the malingering, ED abuse trifecta: Needed a work excuse, seeking pain pills, and wanting an inappropriate antibiotic prescription.

She wore a new pair of shoes to the club, which cramped her toes, which led to fear of an ingrown toenail, which might become infected, so she needed a scrip for antibiotics for that and Vicodin for the pain, and a work excuse for the next day because she stands on her feet all day at work...

... and an ambulance to take her to the ER, because the ER visit is free, and if you come in on a stretcher, everybody knows you get to bypass the waiting room.

14 Y/O female brought to the ER by her mother to have her broken fingernail "wrapped up". Neither PT nor mother could understand why they had to wait to be seen. They were both demanding and rude because after all they did have "insurance". LOL medicaid is insurance right?

had a guy coming in weekly for the past month intoxicated, got a cab voucher each time until his most recent visit when i saw him. tells me "you guys always pay for my ride home." i say to him we can't pay for your transportation every time you come in here intoxicated. storms out angrily and pays for his own cab ride home. guess that'll be a bad press gainey only it was signed out to me so i think the bad survey will go towards the first doc's numbers.

saw 6 patients from a bus accident the day prior- apparently a bus down to dc for the inauguration, on departing dc for the return trip at 4pm, lurched into a pole at ultra-low speed sending its unrestrained passengers flying everywhere.

these 6 patients came in, ~24 hours later, with pain everywhere and each demanding xrays of at least 3 body parts. were all accompanied by some official-looking form which apparently was not for me to fill out.

many xrays later... i did not find a single positive objective finding on any one of these patients. they all have "no fault pending" as their listed insurance (anyone know who will be reimbursing us for these visits?). and who knows how many others went into other local ed's from this "crash."

so there you go- many health care dollars thrown away as a direct consequence of obama's inauguration. (i'm liberal by the way but i thought you guys would enjoy the story)

20ish female + baby daddy and 2 kids arrived via EMS for "a hiccup". Not intractable hiccups or even prolonged hiccups. Just one. She had someone call 911 because she also "has seizures". No seizure, just a hiccup. Seizures well controlled on medication.

The Fort Worth Star Telegram recently had a story about nine people who made 2,700 visits to emergency rooms in Texas at a cost of over $3,000,000.http://www.star-telegram.com/state_news/story/1294112.html

CO (Returning pt) Discharged less than 4 hours earlier. Current CO mild itching. First visit, given steroids, benadryl and script. Did not fill script. Wondering why she did not magically heal in 4 hours.

Dispatched to 'bleeding'. 26 y.o. female with a hangnail. There was a kleenex with a 1mm spot of blood.The pt had Medicaid from an ajoining state, and demanded transport.So, she limped out of her motel room to the ambulance in the parking lot, where we transported her across the street and down 1 block to the hospital.

Last night's winner came in at 0330 from one of the local assisted care facilities. "spitting up a little blood" x1. no dizziness, no orthostatic changes, vitals within norms, no blood visible on scene, none produced when swishing with water. Guess whose system doesn't have EMS initiated refusals?

I once had a young, panicked, 20-something guy come in complaining of a "weird lump" that had appeared on his head in the night. He denied any trauma. Upon palpation I found no lumps on his head. He then had to direct me to a spot with just my index finger. It was a zit. He was in the ED because of a zit.

That one is very similar to a person who called me at 2:00a.m. head pain. on arrival the 30 y/o woman was in the bathroom getting ready to go out for the night. while applying makeup she noticed she had a zit on her forehead and wondered if we could do anything for it. She said she started to "pop" it but her husband stopped her saying if she did it could go to her brain and kill her. She then thought she should call us because she may have partially popped it and wanted to go out for the night and not die.

OK, it wasn't the ER, but it was a Clinic, a Government-Run Clinic where people waited Months to get an appointment...Nice older woman, concerned cause she was passing gas...and it smelled bad...I was an eager Intern so took a pretty thorough history... how long has it been smelling bad, what makes it better, what makes it worse, any associated symptoms, yada yada yada... presented it to the 2d year resident who told me to go fuck myself...

Damn, I hate proof. Every comment is by medical people. I know that's what you asked for, but why does no one who reads this admit to their abuse? There's a ton of them out there. The only way I'm ending up in anyone's ER is unconscious :)

My whole blog is devoted to this topic, but I triaged one recently that came in (MEDICAID!) with c/o a 1/3cmx1/3cm or so area of "irritation" on her ear after getting a perm. She "rushed" right down after the perm "to get it checked out".

62 y/o F called EMS because her "Poop floated". YES. This time after her BM, she looked down to notice that this time it had floated instead of sunk. She also demanded the specimen be brought in for further testing.

Disregarding frank malingering, here are a few more just from the last few days:

1) "It itches under my breasts sometimes"2) "My period is lighter than usual." I asked for a urine sample, and she came back and said, "Oh, now it's about normal." WTF people.3) "The skin on my face is dry." 4) "I was told at X ER, Y ER and X clinic (total of 3 places in 1 week) that I have cancer, but I want another CT to confirm this." [Kinda sad, but still ER abuse]5) "I had a sharp pain in my stomach for about 5 minutes this morning."

From the UK I can recall a chap coming to A&E by ambulance because his new shoes were too tight and he couldn't walk in them. Another chap came in by ambulance because whenever he dorsiflexed his wrist, a vein popped up on the volar surface. He wanted to know if this was normal -it was, he wasn't.

I work as a tech in a mid-sized town in Michigan. I was checking in patients at triage when this young twenty-something girl came in with a friend, holding a towel around her index finger, dramatically waving her hand around and yowling in pain. I asked her if she could remove the towel so I could see the finger, thinking there was a lac--I needed to put that as the "chief complaint" if there was one. She carefully removed it and I saw...nothing. Well, nothing but an artificial nail that was bent back at a strange angle, separated from the natural nail. When I asked what she would like to be seen for, she stated--yelled--that she ripped her artificial nail off and it huuuuuurrrttt!! So, since we can't turn patients away, we checked her in. Got vital signs. Took up a room (probably in fast track but still), took up the time of the ER staff all because this chick didn't have the common sense to a) put a band-aid on b) go see the nail tech that put the nail on in the first place and c) suck. it. up.

One of our frequent flyers was brought in by the ambulance for a "bad sunburn".

A 25-year-old man with chronic low back pain takes a medical van, paid for by the state, to my urgent care during a huge snowstorm and arrives 10 minutes before closing and tells me he "wants to get to the bottom of" his back pain. Had just received his monthly 120 Percocet from his PA primary. I tell him that is just NOT going to happen at this time of night and spend 20 minutes trying to figure out how the hell I might actually be able to help while I have an actual sick wheezing kid next door. Finally I had to leave to check on the kid and he leaves and CALLS AN AMBULANCE FROM OUR LOBBY and goes to the ER. Trust me I called that ER to let them know about the recent 120 Percs.

Last week a girl came in worried she had "blood poisoning"--she had a tiny little extremely superficial scratch on the inside of her elbow. WTF?

25 -YEAR-OLD male with bilateral nephrectomies, 3x/week dialysis calls ambulance on dialysis days because he weak and dizzy, noncompliant with meds, skips dialysis appointments. Called EMS at leat five times in one month. The last time mother called local PD to assist her in getting her son into the car so SHE can take him in. PD had not even arrived when the page went out for the ambulance to that address. On EMS arrival, Mom smiling and waving on the steps of their trailer house and said "Oh good, the ambulance is here, now I can stay home and work on my unemployment."

No kidding, 34yo male fall from standing on carpet complaining of non-specific body pain plus neck pain and positive LOC per patient. No other history other than HTN and slightly obese. Upon pre-hospital exam the slightest most delicate touch to any part of the patient body caused him to shout defining tones of pain in EMT's ear. A “100” on the 1-10 pain scale per patient. EMS is forced to C-spine and backboard and carry 250lb patient down three flights of stairs, and up a snow covered embankment. Upon detailed history patient admitted "lortab just doesn’t do it anymore" Dx in ED for non-specific body pain and Rx script of hydrocodone x 30, oxytcotin x 10 PRN and a shot of morphine after which patient self- ambulated out of ED with a smile. Upon EMS investigation patient had been to the ED 50+ times for the same CC within the last 6mo. Same MOI and Rx happy endings. After competing this self- initiated report to EMS command staff and confronting ED docs directly- EMT was reprimanded for possible HEPA violation and suspended for one day without pay with a letter on permanent record.

SO here is a case in point to all ED Docs and naive well wishers that if you stop giving schedule II pain meds like it was candy then perhaps we can have health reform instead of EMT broken backs! Oh and in case if you are wondering patient has not been investigated further nor has been entered into the West Virginia drug seeker database as of this post.

Mother brings in 12 year old daughter with a nosebleed - because "her period is coming out her nose." Man comes in with girlfriend because a vein on his leg is red and sore and "jumping". He admits to shoot up cocaine at site - girlfriend wants to know if this is normal. I told her that there is nothing normal about shooting up your leg veins with cocaine. DUH!